New Patient Form Packet

Please Complete the Entire Form Packet ONLINE Below

Please do NOT attempt to print or hand-write responses on this form. Hand-written responses will not be accepted.

Please make sure you have allocated enough time to complete the form entirely. You will not be able to save and return to it – the entire form packet must be completed in one session.

Patient Intake Form: Policies & Procedures for our Patients Receipt Acknowledgement Form

1. Medication refills should be requested at time of the patient's appointment. If the patient fails to notify the physician/practitioner that a refill is required before the next appointment, there may be a $25 charge rendered for the service.

2. Should there be a change of pharmacy requested after a prescription is written, there may be a charge of $25 rendered.

3. If a patient is more than 10 minutes late for the scheduled appointment, they may not be seen and the appointment will have to be rescheduled. The patient will be charged wit ha late cancellation fee of $75 for that appointment.

4. When a patient finds a need to call to change an appointment, they should be aware that there might not be sufficient supplies of medication to last until the new appointment. It is the patient's responsibility to ask for a medication extension at the time of the appointment change. Failure to take this initiative may result in the charge of a fee for this service.

5. Should a patient fail to show for a scheduled appointment, there will be a $75 fee for the first occurrence; for 2nd occurrence the fee is $100; the 3rd occurrence is $150. PASWFL may elect to not make any further appointments after three failures to show. **Please note that No-Show charges are the patient's responsibility and cannot be billed to any insurance company.**

6. We will be performing random urine drug screens two times per year. If you refuse this, PASWFL has the right to refuse to provide you psychiatric services.

7. It is our expectation that all accounts be kept up-to-date at the time of each visit.

To Our Valued Patients: Since the implementation of the Affordable Care Act or "Obama Care", we have experienced a drastic increase in prior authorization requests for routine prescription medications. This, along with ongoing changes to prescription formularies, has rendered us no longer able to anticipate what medications will be covered by your individual plan or policy.

In the past, we have processed such requests as a courtesy, on behalf of our patients. Unfortunately, Psychiatric Associates of SWFL staff members will no longer be able to offer this courtesy service.

What now?

Prior authorizations for medications can be initiated by you, as the patient through your insurance company. We recommend contacting your local pharmacy, mail order service and or insurance company itself to see if you medication needs authorization to be filled. If it is required, you can ask to initiate the process immediately. Please keep in mind there is a process and time line each insurance company has set in place for their authorization process.

Tips:

Know your plan benefits and formulary. You can obtain it through your insurance company or HR department if insurances through your employer. You can call to initiate it over the phone. Ask the pharmacy for the information that they were given when the "claim" was sent from them to your insurance at the time of the prescription being filled. If you use a mail order service, call the number listed on the bakc of your card or the prscription card if separate. If your insurance company requires a signature fro myour provider, please bring the forms iwth you to the visit or into the office and we will have them signed. Please note: turnaround time may vary based off your specific providers schedule, time/day of the week. Check your insurance carrier's website for any online member portals that may help speed up the process.

We apologize for any inconveniences. PASWFL Office Management Team.

Date of Signing

Year

Acknowledgement

I agree.

I do not agree.

Patient Intake Form: Patient Registration

Date of Birth

Social Security Number

Gender

Local Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Out of State Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Name of Responsible Party (if patient is a minor)

Prefix First Last Suffix

Relationship to Patient

Primary Insurance Provider

Subscriber Name

Secondary Insurance Provider

Referring Physician

Referring Physician Phone

Assignment of Benefits - Confirmation

I hereby assign, transfer and convey all medical benefits to be paid directly to PASWFL - Dr. Robert W. Pollack. I recognize it is my responsibility to pay for all non-covered services.I also authorize PASWFL to release any information necessary to process an insurance claim. In the event the patient is a minor, a parent or guardian who will be responsible for the payment of the bill must accompany the patient. A photocopy of this Assignment will be considered as valid as the original.

I agree.

I do not agree.

Assignment of Benefits - Date of Signature

Year

Please Complete the Entire Form Packet ONLINE Below

Patient Intake Form: Questionnaire for New Patients

Patient Intake Form: Policies & Procedures for our Patients Receipt Acknowledgement Form

Patient Intake Form: Patient Registration

Patient Intake form: Medical History

Patient Health Questionaire - 9

Over the last 2 weeks, how often have you been bothered by any of the following problems?

In Closing

DEPRESSION IS VERY REAL. BUT THERE IS HOPE.

DISCLAIMER

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